Hospital staff failed to assess cancer patient properly - report

Hospital staff failed to assess a patient properly, causing delays in her being diagnosed with cancer, a report has revealed.

The Parliamentary And Health Service Ombudsman investigated a complaint about Wrightington, Wigan And Leigh NHS Foundation Trust after the woman was diagnosed with thyroid cancer at another hospital.

The inadequate assessment in the A&E department in summer 2012 and the failure of trust staff to provide her with a neck brace in early summer 2013 fell so far below established good practice that it amounted to a failure in service

Their report says the patient, identified only as Mrs W, went to her GP in summer 2010 with hoarse speech.

She was referred to the trust’s ear, nose and throat (ENT) service, diagnosed with vocal cord palsy and had speech therapy.

But in summer 2012, she collapsed with breathing difficulties and went to A&E.

She was discharged into the care of her GP, who carried out blood tests which found she had an overactive thyroid.

She was referred to another hospital trust and tests showed she had thyroid cancer, which had spread to her muscles and lymph nodes.

She had surgery and radiotherapy and was told the cancer had spread to her spine.

In summer 2013, Mrs W went to Wigan A&E and tests showed the cancer had spread to other parts of her spine.

Her family wanted her to be transferred back to the second hospital trust and despite advice from specialists that she should be fitted with a neck brace during the transfer, it was not done.

Mrs W died a month later.

The ombudsman partly upheld the complaint. They found the ENT staff had investigated her symptoms appropriately, but she was not assessed adequately in A&E in 2012, so there was a delay in treating her breathing difficulties and finding the cancer.

However, the delays did not affect her prognosis, they said.

The report states: “The inadequate assessment in the A&E department in summer 2012 and the failure of trust staff to provide her with a neck brace in early summer 2013 fell so far below established good practice that it amounted to a failure in service.”

The ombudsman said the trust had acknowledged its failure in service, apologised to her husband and given him £500.

It prepared an action plan to show what it had done to make sure staff learned from the failings and explained what it had done to avoid it happening again.

The ombudsman also looked into complaints about arrangements for a woman in her late 80s when she was discharged from hospital to a nursing home.

She was given someone else’s medicine, did not have her handbag or heading aids and the nursing home was not told she was being discharged.

The ombudsman found that although there were shortcomings in the discharge arrangements, the trust had apologised and taken measures to prevent it happening again, so they did not uphold the complaint.

The cases were among 100 published in a report by the ombudsman providing a snapshot of the complaints it received between October and December last year.

Pauline Law, director of nursing at the trust, said: “Mrs W’s treatment and care under the ENT department in 2011 were found to be appropriate and there were no failings identified. However the PHSO’s findings highlighted two points following her subsequent attendances at WWL’s emergency care centre in 2012 and 2013. The trust accepted the findings of the PHSO and sincerely apologised for the failings identified, as whilst the delays in diagnosis and treatment did not affect the prognosis we would not wish to cause any unnecessary distress to the patient or their family.

“An action plan was undertaken in order to learn from this sad outcome and financial redress was awarded.

“The second case highlighted within the PHSO report was not upheld as it was recognised that the trust had met with the family, extended our sincere apologies and taken reasonable and proportionate action, where necessary, to prevent a recurrence of similar events. The trust uses complaints to learn from and as always we welcome the views of people who have experience of using our services, even if they are critical.”